Other person/sources of information:
Mother, Father, School Teacher
Services involved:
Social Services, School Counselling
Protected characteristics:
Diagnosed with ADHD, struggles with reading due to dyslexia.
Child safeguarding:
Child lives with both parents, who have parental responsibility. No current safeguarding concerns.
Household composition:
Lives with both parents and younger sister.
History of Presenting Complaints:
Patient presents with symptoms of low mood, irritability, and difficulty concentrating. These symptoms have been present for approximately 6 months, with a gradual onset. The patient reports feeling sad most days, experiencing a loss of interest in activities they previously enjoyed, such as playing video games and spending time with friends. They also report difficulty sleeping, with frequent awakenings during the night. The patient's appetite has decreased, and they have lost weight. The patient reports feeling overwhelmed by schoolwork and struggles to focus in class. They have also reported feeling hopeless about the future.
The impact of the problem on day-to-day activities includes difficulty getting out of bed in the morning, reduced participation in school, and withdrawal from social activities. The patient's personal hygiene has been affected, with less attention paid to grooming. They are struggling to complete homework assignments and their grades have declined. They are also experiencing increased conflict with their parents.
Associated symptoms include feelings of worthlessness, excessive guilt, and recurrent thoughts of death. The patient reports these thoughts occur several times a week and last for a few minutes each time. They have not made any plans to harm themselves.
Precipitating Factors:
Increased academic pressure, bullying at school, and recent arguments with parents.
Perpetuating Factors:
Social isolation, negative self-talk, and avoidance of schoolwork.
Social History:
Patient is currently attending secondary school and is struggling academically. They have a few close friends but have withdrawn from social activities recently. They live in a stable home environment with their parents and sister. They have limited access to financial resources.
Personal history includes a history of being a happy and outgoing child. They enjoyed playing sports and spending time with friends. They have always had a close relationship with their parents. They have experienced bullying at school in the past.
Patient is able to perform essential independent living skills, including personal care, eating/drinking, and household tasks.
Past Medical & Psychiatric History:
- Diagnosed with ADHD at age 8.
- No prior psychiatric hospitalizations.
- Chronic medical conditions: Asthma
Child Development:
Normal birth and developmental milestones. No complications during pregnancy or delivery.
Forensic/Offending History:
No reported forensic or offending history.
Premorbid Personality:
Patient was previously described as a happy, outgoing, and resilient child. They were able to form and maintain relationships and cope with stress. They enjoyed playing sports and spending time with friends.
Medications:
- Methylphenidate 10mg twice daily for ADHD.
Family History:
Mother has a history of depression. Father has a history of anxiety.
Mental Status Examination:
Appearance: Appears dishevelled, with unkempt hair and clothing. Appears their stated age.
Behaviour: Restless and fidgety, with poor eye contact.
Speech: Slowed speech, with a low volume and monotone tone.
Mood: Patient reports feeling sad and hopeless.
Affect: Restricted affect, with limited emotional expression.
Thoughts: Reports feelings of worthlessness and recurrent thoughts of death.
Perceptions: No hallucinations or sensory misinterpretations.
Cognition: Oriented to time, place, and person. Memory intact. Concentration is impaired.
Insight: Limited insight into their condition.
Judgment: Judgment appears impaired.
Risk Assessment:
Risks to self: Reports recurrent thoughts of death, but denies suicidal ideation or plans. No current risk of self-harm.
Self-harm: No reported self-harm risks.
Risks to others: No reported risks to others.
Substance use: No reported substance use concerns.
Risks from others: No reported risks from others.
Protective factors: Supportive family, previous positive coping strategies.
Service User Views and Goals:
Patient would like to feel happier, improve their mood, and improve their concentration in school.
SMART Goal 1:
Improve mood and reduce symptoms of depression within 8 weeks.
SMART Goal 2:
Improve concentration and academic performance within 12 weeks.
Initial Formulation/Impression:
Patient presents with a moderate depressive episode, likely triggered by academic pressure and bullying. The patient's ADHD and dyslexia may be contributing factors. The patient is at risk of self-harm. The patient is motivated to engage in treatment. The patient is likely to benefit from a combination of psychotherapy and medication.
Recommendations / Agreed Action Plan:
- Initiate Cognitive Behavioral Therapy (CBT).
- Increase methylphenidate dosage.
- Schedule follow-up appointment in 2 weeks.
- Refer to educational psychologist for further assessment.
Risk Assessment Formulation:
Predisposing factors: Family history of mental illness, ADHD, and dyslexia.
Precipitating factors: Academic pressure, bullying, and arguments with parents.
Perpetuating factors: Social isolation, negative self-talk, and avoidance of schoolwork.
Protective factors: Supportive family, previous positive coping strategies.
My Staying Well Plan:
My safety and wellbeing: I will contact my parents or therapist if I feel overwhelmed or have thoughts of harming myself. I will avoid situations that trigger my low mood, such as school.
Signs I need additional support: Feeling sad most days, loss of interest in activities, difficulty sleeping, and thoughts of death.
How I cope: I will talk to my parents, engage in activities I enjoy, and practice relaxation techniques. I can contact my therapist, my parents, or my friends.
Giving support: I want my parents and therapist to help me manage my symptoms and support me.
Staying well: I will engage in activities I enjoy, spend time with friends, and practice relaxation techniques.
Mental Wellbeing Intervention Plans:
Identified needs: Low mood, difficulty concentrating, academic difficulties, and social isolation.
Interventions: CBT, medication management, educational support, and social skills training.
Consent to Care:
Patient and parents were informed about the CAMHS services and confidentiality. The care plan, risks of not engaging, benefits, and alternatives were discussed.
About Me:
My Story: I have been struggling with low mood, difficulty concentrating, and academic difficulties. I have always enjoyed playing video games and spending time with friends. I have a supportive family.
My health and wellbeing, and how I want my life to change: I want to feel happier, improve my mood, and improve my concentration in school.
What is important to me?: Spending time with friends, playing video games, and doing well in school.
My individual needs: Support with my ADHD and dyslexia. Reasonable adjustments at school.
My strengths: Supportive family, previous positive coping strategies, and a desire to improve.
The views of my family, friends and people who are in my life: My parents are concerned about my mood and want me to get better. My friends are supportive and want me to feel better.
Talking to Family and Friends about my health and wellbeing: I consent to my parents and therapist discussing my wellbeing.
Other person/sources of information:
[Enter any other contributors or sources of information to the assessment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Services involved:
[Enter any other agencies involved currently and in the past] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Protected characteristics:
[Identify any disabilities the person has, how their day-to-day activities are limited because of a health problem or disability] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Child safeguarding:
[Describe care arrangements including who has parental responsibility] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Household composition:
[List who the child lives with such as parents, siblings, other family members and pets] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
History of Presenting Complaints:
[Describe current issues with all available details, reasons for visit, and complete history of presenting complaints such as symptoms, frequency, impact, duration and onset.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in paragraphs.)
[Describe the impact of the problem on day-to-day activities including sleep, appetite, personal hygiene, education, home and social functioning] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in paragraphs.)
[Describe any other associated symptoms with details such as frequency, onset, duration, triggers and strategies used] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in paragraphs.)
Precipitating Factors:
[What originally triggered the problem, life changes happening around the time that the presenting complaints began e.g. home move, school move, friendship issues, bullying, stress, trauma, family events, exams, bereavement] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Format as list or paragraph.)
Perpetuating Factors:
[Describe factors that keep the presenting concerns going e.g. avoidance, environmental factors, use of coping strategies, support networks] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write in paragraphs.)
Social History:
[Current social circumstances, including relationships and support networks, housing and finance, school, use of social/recreational time] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Personal history, including significant life events, key memories or touchstones, previous interests, key relationships and friendships] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Information about ability to perform essential, independent living skills including personal care such as washing, dressing, brushing hair, cleaning teeth, shaving, putting on make-up; eating/drinking; sleep; and household tasks such as shopping, food preparation, housekeeping, laundry] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Past Medical & Psychiatric History:
[Describe past psychiatric diagnoses, treatments, hospitalizations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write as list.)
[List chronic medical conditions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Write as list.)
Child Development:
[Birth and development history, including substances during pregnancy, condition at birth and milestones] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Forensic/Offending History:
[Forensic history/offending history] (If there is no explicitly mentioned forensic or offending history, summarise that there were no reported forensic or offending history.)
Premorbid Personality:
[Assessment of how the individual would describe their personality before becoming unwell. Coping styles, interests and activities, ability to relate to others, sustain relationships, and cope with stress and loss] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Medications:
[List current medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Family History:
[Note any psychiatric illnesses within the family, specifying the relationship to the patient and the nature of the illnesses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Mental Status Examination:
Appearance: [Describe the patient's clothing, hygiene, and any notable physical characteristics] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Behaviour: [Observe the patient's activity level, interaction with surroundings, and notable behaviours] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Speech: [Note rate, volume, clarity, and coherence of speech] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Mood: [Record the patient’s self-described emotional state, using their own words if possible] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Affect: [Describe emotional range and appropriateness during exam, noting any discrepancies with mood] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Thoughts: [Assess thought process and content; note distortions, delusions or preoccupations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Perceptions: [Note hallucinations or sensory misinterpretations, specifying type and impact] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Cognition: [Describe memory, orientation to time/place/person, concentration, comprehension] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Insight: [Describe understanding of condition and symptoms, awareness or denial] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Judgment: [Describe decision-making ability and understanding of consequences] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Risk Assessment:
Risks to self: [Assessment of suicidality, risk indicators, frequency, onset, duration, associated symptoms, and risk-enhancing circumstances] (If not mentioned, summarise that there were no reported risks to self.)
Self-harm: [Assessment of self-harm, frequency, onset, associated symptoms, risk-enhancing circumstances] (If not mentioned, summarise that there were no reported self-harm risks.)
Risks to others: [Assessment of homicidality, risk indicators, frequency, onset, associated symptoms, risk-enhancing circumstances] (If not mentioned, summarise that there were no reported risks to others.)
Substance use: [Assessment of alcohol/substance use, type, quantity, pattern, route, risk behaviour, criminality, OTC/prescription misuse] (If not mentioned, summarise that there were no reported substance use concerns.)
Risks from others: [Assessment of safeguarding concerns, contact with social care, police, abuse, neglect, or threats] (If not mentioned, summarise that there were no reported risks from others.)
Protective factors: [Protective actions, strengths, coping strategies, relationships, insight, motivation for change] (If not mentioned, summarise that there were no reported protective factors.)
Service User Views and Goals:
[Review of what the young person would like to achieve, changes desired, aspirations for life and mental health] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
SMART Goal 1:
[Briefly state or list the goal(s) or changes to be achieved by the patient for SMART goal 1] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
SMART Goal 2:
[Repeat SMART goal format only if second SMART goal was mentioned in transcript or clinical note] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Initial Formulation/Impression:
[Recap pertinent history and current info, clinical impression, factors contributing to and maintaining problems, risks, service user goals, treatability, appropriate interventions, motivation, engagement or compliance] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Recommendations / Agreed Action Plan:
[Planned investigations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Psychotherapy plans and strategies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Family meetings, collateral info, psychosocial interventions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Follow-up plans and referrals. Record discharge rationale if not requiring MH services] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Risk Assessment Formulation:
Predisposing factors: [Explain why the service user was at risk in the past, summarising relevant personal history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Precipitating factors: [Early warning signs and risk-increasing factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Perpetuating factors: [Ongoing life factors maintaining risk] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Protective factors: [Factors that may help reduce or limit risk] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
My Staying Well Plan:
My safety and wellbeing: [Explain safety concerns and triggers, including significant dates] (Phrase in first person. Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Signs I need additional support: [Warning signs or early signs of mental health deterioration] (Phrase in first person. Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
How I cope: [What helps, past effective strategies, who they can contact, detailed safety plan] (Phrase in first person. Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Giving support: [What they want family/friends/staff to do if their health worsens] (Phrase in first person. Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Staying well: [What’s important to maintain safety: activities, coping tools, people, reasons for living] (Phrase in first person. Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Mental Wellbeing Intervention Plans:
Identified needs: [Bullet-point list of identified health, wellbeing, and support needs] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Interventions: [Summary of support offered and follow-up actions including coping strategies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Consent to Care:
[Summarise the information provided about CAMHS and confidentiality] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Summarise care plan discussions, risks of not engaging, benefits and alternatives] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
About Me:
My Story: [Circumstances leading to service contact, life experiences, what worked, roles, strengths, impact of mental ill-health] (Phrase in first person. Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
My health and wellbeing, and how I want my life to change: [Feelings about wellbeing, goals for the future] (Phrase in first person. Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
What is important to me?: [Things that help or worsen their mood; values; preferred treatment approaches] (Phrase in first person. Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
My individual needs: [Support needed, disabilities, aids, reasonable adjustments] (Phrase in first person. Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
My strengths: [Strengths, what’s going well, support network, helpful qualities] (Phrase in first person. Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
The views of my family, friends and people who are in my life: [Summary of others’ views] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
Talking to Family and Friends about my health and wellbeing: [Who the young person consents to speak with regarding their wellbeing] (Phrase in first person. Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
